Client Intake Form Name * First Name Last Name Partner's Name First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Partner's Phone * (###) ### #### Email * Do you have any other medical conditions I should be aware of? If so please note below. * Baby's name(s) and estimated birth date * Is this your first baby? If not, please list other child(ren)s name and age(s) * Intended place of birth and OB/Midwife's name * Are you taking time off work and if so how long? Is your partner taking time off work and if so how long? Any food or other allergies in the family? * Do you have any pets in the home? If so please note and include any special instructions * Do you or your partner smoke in the home? * How do you plan to feed your baby? * Breastfeeding Formula Combination Exclusive Bottle/Pumping Other Are there any parenting techniques you plan to use or have questions about? What are your primary goals in having a Postpartum Doula? * How did you hear about my services? Do you have a history of postpartum mood disorders or mental health concerns? * Do you have any fears about parenting or the postpartum period? What time of day do you anticipate Postpartum Doula services will be the most needed? What tasks do you anticipate you will like the most help during the postpartum period? Anything you would like to add? Privacy Policy and Disclaimer: All of your personal information will be kept private and will never be shared with anyone and will be used solely to help me best support you. It is your responsibility to share any and all relevant medical information with your healthcare provider. As a Postpartum Doula, I do not offer any medical advice. If you have any medical concerns or issues, I can refer you to seek care from the appropriate qualified medical professionals. Thank you for your information! I am looking forward to supporting you and your family!
